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BRIEF COMMUNICATION
Year : 2018  |  Volume : 6  |  Issue : 3  |  Page : 111-113

Open globe injury secondary to a dog bite presenting to a tertiary care hospital


Department of Ophthalmology, Goa Medical College and Hospital, Bambolim, Goa, India

Date of Web Publication23-Oct-2018

Correspondence Address:
Marushka Aguiar
F01/02, Building 4C, Models Legacy, Near Skoda Showroom, Taleigao, Bambolim - 403 206, Goa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcor.jcor_78_17

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  Abstract 


We are presenting a rare case of an open globe injury in a 75-year-old female secondary to a bite from a stray dog involving her face and right eye which had a large lid laceration and a full-thickness corneoscleral tear. The visual acuity was reduced to the perception of light. There was circumcorneal as well as ciliary congestion. The cornea showed a 5 mm × 2 mm × 0.5 mm tear with surrounding corneal haze. The anterior chamber was shallow with a hyphema. There was no view of the iris, pupil, and lens. The patient was given anti-rabies immunoglobulin infiltration as well as anti-rabies vaccine as per schedule. Stay sutures were placed for the scalp avulsion, and lid laceration and patient was taken to operation theater for corneoscleral suturing. The patient has been followed up 6 weeks after suturing. Visual prognosis remains poor.

Keywords: Anti-rabies vaccine, dog bite, open globe injury


How to cite this article:
Aguiar M, S. Usgaonkar UP. Open globe injury secondary to a dog bite presenting to a tertiary care hospital. J Clin Ophthalmol Res 2018;6:111-3

How to cite this URL:
Aguiar M, S. Usgaonkar UP. Open globe injury secondary to a dog bite presenting to a tertiary care hospital. J Clin Ophthalmol Res [serial online] 2018 [cited 2018 Dec 14];6:111-3. Available from: http://www.jcor.in/text.asp?2018/6/3/111/243846



We have reported this case as the incidence of open globe injuries following dog bites is only 1%–2%.[1] Animal bites are usually very deep due to the force of the bite. This force also causes inoculation of pathogenic microbes from the saliva into the wound. Hence, there are higher chances of infection. Infection is further aggravated by crushed necrotic tissue as a result of this bite force. Ocular bites are not very common, though when they occur, they are associated with severe ocular adnexal injury, especially to the lids and canalicular system. Dog bite injuries over the head, face, and neck are classified as Class III injuries and have the highest risk of transmission of rabies. Important points in preventing infection are a thorough cleansing of the wound, preventing further tissue damage, primary closure if the wound is low-risk for developing an infection, rabies postexposure prophylaxis and rabies immunoglobulin at the site.


  Case Report Top


A 75-year-old woman presented to casualty with history of injury to the face and right eye secondary to a stray dog bite.

There was a history of sudden painful decreased vision in the right eye with a gush of warm fluid from her eye. The patient gave history of good vision before this incident and history of both eyes being operated for cataract 7 years ago with intraocular lens implantation and good postoperative vision. The patient had no systemic comorbidities. On examination, her vitals were stable. There was a full-thickness eyelid laceration measuring 6 cm × 1 cm × 0.5 cm with an avulsion of the skin of forehead extending until the cranial vault. Tissue loss was noted.

The anterior segment of the left eye was within normal limits with an intraocular lens in situ and visual acuity of 6/9 by Snellen's chart.

The patient's visual acuity in the right eye had reduced to the perception of light, with inconsistent light ray projection. There were right eyelid edema and periorbital ecchymosis. On slit lamp examination, there was a corneoscleral tear approximately 5 mm × 3 mm × 0.5 mm with surrounding cornea edema. There were circumcorneal and ciliary congestion. The anterior chamber was shallow with Grade 1 hyphema. Details of the iris, pupil, and lens were not clearly visible. The globe was digitally soft, consistent with the findings of an open globe injury.

After asking the patient to close her eyes, the face and scalp wounds were washed thoroughly with soap and water for 5 min. The eyelid lacerated wound was washed gently but thoroughly with normal saline. The patient received active and passive management for rabies as well as tetanus toxoid, analgesics, and antibiotics.

As the avulsion was so large, stay sutures were placed in the ward and patient was shifted to OT for suturing of the open globe injury. The patient was given peribulbar anesthesia. The eyelids were cleaned with povidone-iodine gently to prevent further extrusion of ocular contents. The patient was draped and wire speculum positioned. The corneoscleral wound was sutured first with 10-0 nylon interrupted sutures. An anterior chamber lavage was done and reformed. Subconjunctival injection of dexamethasone and gentamycin was given prophylactically. The stay sutures were removed, and the eyelid wound was irrigated again with normal saline. The eyelid was sutured in layers with 6-0 vicryl and 4-0 silk sutures.

The patient was started on intravenous antibiotics (cefotaxime 1.2 g 12 hourly and metronidazole 500 mg 8 hourly) topical antibiotic-steroid eye drops (gatifloxacin 0.3% w/v + prednisolone 1% w/v), cycloplegic eye drops (atropine sulfate 1% w/v) thrice a day and an antibiotic steroid eye ointment (chloramphenicol 10 mg + dexamethasone 1 mg + polymyxin B 10000 IU) at night.

The patient was discharged and told to follow-up after 1 week and advised to follow her anti-rabies vaccine schedule (0, 1, 3, 7, 14, 21, and 30) [Figure 3].
Figure 1: Slit lamp image showing corneoscleral tear well apposed with hyphema

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The patient was not very compliant and thereafter followed up after 1 month.

On examination, the corneoscleral tear was well apposed with interrupted sutures. The surrounding cornea appeared decompensated [Figure 1].
Figure 2: Slit lamp image showing corneoscleral tear well apposed with 10-0 nylon sutures and hyphema

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The anterior chamber had an irregular depth with a blood clot in situ [Figure 2].
Figure 3: Patient reviewed 1-week post-operative. Corneal decompensation noted with blood clot in anterior chamber

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Iris was normal; her pupil was irregular and not reacting to light. Posterior chamber intra-ocular lens noted in situ. Intra-ocular pressure was on the lower side but digitally formed.

The postoperative B-scan showed a retinal detachment.

The eye is now blind.

The patient was further referred to plastic surgery for forehead flap reconstruction due to tissue loss [Figure 4].
Figure 4: Patient at 6 weeks post-operative. Healed lid laceration noted with tissue loss requiring forehead skin flap

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  Discussion Top


Even in the presence of severe periocular lacerations caused by dog bites, the eye is usually undamaged. In general, the dog's blunt tooth pushes the globe out of the way. Injuries sustained in the area of ocular adnexa and lids probably protect the globe itself from injury. Furthermore, due to the blink reflex, the lids, adnexa, and lacrimal apparatus bear the brunt of dog bite injury protecting the globe.[1] The incidence of open globe injuries following dog bites is very rare with only a 1%–2% incidence.[2] Although visual outcome in cases of open globe injuries is very variable and depends on factors such as size and site of injury, the presence of an afferent pupillary defect, visual acuity at presentation, concomitant hyphema, lens extrusion, and retinal detachment, all measures must be taken to prevent rabies in such a case. Timely detection, early management, and patient cooperation for follow-up can lead to a better postoperative visual outcome.


  Conclusion Top


Although the visual recovery, in this case, was poor due to underlying retinal detachment, major complications such as post open globe endophthalmitis, central nervous system infection and septicemia were averted. Timely referral to tertiary centers with facility for primary repair is key. The patient should receive both active and passive immunization in such a case.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Singh B. Analysis of ocular injury cases caused by dog bite and their prevention. IOSR J Dent Med Sci 2016;15: Pp 16-18.  Back to cited text no. 1
    
2.
Prendes MA. Ocular trauma from dog bites: Characterisation, associations, and treatment patterns at a regional level I trauma center over 11 years. Ophthalmic Plast Reconstr Surg 2016;32:279-83.  Back to cited text no. 2
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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